Perineorraphy: Restoration of Vaginal Opening Looseness
Frederick R. Jelovsek MD
"My doctor has told me that I need to have vaginal reconstruction due to the problems childbirth caused me. He is not pushy about it but says it is my decision whether it would be worth it to have the surgery. My problems are urinary incontinence, vaginal dryness because I am "wide open", and intercourse is not as pleasurable because of my muscles being so weak and loose. I don't know if this is recommended or is my problems just something I have to live with since they are not a medical necessity?
Background: I am 36 and have had 2 children. I am in overall good health and in good shape. I have had a hysterectomy due to fibroids. I still have my ovaries, and my estrogen level is fine. I have vaginal infections quite often. I have been tested for diabetes, and lupus. Negative. I think I have vaginal infections often because of the dryness that is caused by being exposed to air inside me. I know this sounds quite weird. " rj
This is not weird. It is just not expressed very often by women but I suspect there are many more women like you that have this problem. Basically the vaginal opening has been stretched larger due to childbirth. It sounds as if in your case the stress incontinence is bad but the gaping of the perineal opening is of the most concern.
What causes vaginal opening enlargement and decreased pleasure with intercourse?
Many try to blame the use of episiotomy and forceps during delivery of a child as the cause for perineal enlargement and subsequent pelvic organ prolapse. Perhaps the question of how much those factors contribute rather than just the size of the baby relative to the mothers vaginal and perineal size and tissue elasticity, will never be fully answered. Large babies and long difficult labors in the pushing stage can, in some women, result in symptoms of incontinence, bladder and rectal dropping and enlargement of the vaginal opening called the genital hiatus.
It has been established that the genital opening is indeed larger in women with pelvic prolapse (1). In fact it can be 2 or even 3 times larger in the increasing degrees of pelvic prolapse and even when the prolapse is corrected, it may not go back to normal size.
In addition to a permanent enlargement of the opening, there is often injury to the nerve (pudendal) that controls sensation and muscle contraction of that muscle at the opening (2). It does not seem to be the nerve injury that causes prolapse of the perineum but rather that nerve injury also takes place with the injury to support structures (3).
Are there non-surgical treatments for perineal relaxation?
The traditional non surgical treatment for relaxation of the vaginal opening has been Kegel exercises. These are isometric contractions of the muscle at the vaginal opening that are held for a period of time (seconds) and then repeated. They have been shown to help reduce mild urinary stress incontinence but not moderate and severe incontinence (4). Starting them during pregnancy may even help (5). Other treatments such as vaginal cones (6) may be as good or even more effective.
What is the surgical treatment for repair of the vaginal opening (perineum)?
Surgical therapy of this problem is called a perineorraphy. It is a reconstruction of the muscles and tissues at the open of the vagina. It is often performed with other pelvic relaxation surgery such as rectocoele repair. The procedure is very good at decreasing the size of the vaginal opening but as with any surgery, there can be further nerve damage to the muscles which lessens the sensation at the opening. There also is a slight risk of scarring of the skin right at the opening which can make intercourse painful. Therefore the surgery must not be undertaken lightly.
Most of the time women do not mention to the physician how bothersome the looseness of the opening is. Doctors do not automatically just perform surgery because they think the opening is too loose. there needs to be a concern expressed by the woman. Be sure to be bold enough to discuss this problem with your doctor before surgery so you will not be disappointed by assuming something will change just because of the other components of surgical repair surgery.
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